Risk factors for ventilator-associated pneumonia in patients with severe traumatic brain injury in a Serbian trauma centre.

INTRODUCTION: The aims of this study were (1) to assess the incidence of ventilator-associated pneumonia (VAP) in patients with traumatic brain injury (TBI), (2) to identify risk factors for developing VAP, and (3) to assess the prevalence of the pathogens responsible. PATIENTS AND METHODS: The following data were collected prospectively from patients admitted to a 24-bed intensive care unit (ICU) during 2013/14: the mechanism of injury, trauma distribution by system, the Acute Physiology and Chronic Health Evaluation (APACHE) II score, the Abbreviated Injury Scale (AIS) score, the Injury Severity Score (ISS), underlying diseases, Glasgow Coma Scale (GCS) score, use of vasopressors, need for intubation or cardiopulmonary resuscitation upon admission, and presence of pulmonary contusions. All patients were managed with a standardized protocol if VAP was suspected. The Sequential Organ Failure Assessment (SOFA) score and the Clinical Pulmonary Infection Score (CPIS) were measured on the day of VAP diagnosis. RESULTS: Of the 144 patients with TBI who underwent mechanical ventilation for >48h, 49.3% did not develop VAP, 24.3% developed early-onset VAP, and 26.4% developed late-onset VAP. Factors independently associated with early-onset VAP included thoracic injury (odds ratio (OR) 8.56, 95% confidence interval (CI) 2.05-35.70; p=0.003), ISS (OR 1.09, 95% CI 1.03-1.15; p=0.002), and coma upon admission (OR 13.40, 95% CI 3.12-57.66; p<0.001). Age (OR 1.04, 95% CI 1.02-1.07; p=0.002), ISS (OR 1.09, 95% CI 1.04-1.13; p<0.001), and coma upon admission (OR 3.84, 95% CI 1.44-10.28; p=0.007) were independently associated with late-onset VAP (Nagelkerke r(2)=0.371, area under the curve (AUC) 0.815, 95% CI 0.733-0.897; p<0.001). The 28-day survival rate was 69% in the non-VAP group, 45.7% in the early-onset VAP group, and 31.6% in the late-onset VAP group. Acinetobacter spp was the most common pathogen in patients with early- and late-onset VAP. CONCLUSIONS: These results suggest that the extent of TBI and trauma of other organs influences the development of early VAP, while the extent of TBI and age influences the development of late VAP. Patients with early- and late-onset VAP harboured the same pathogens.

Distal ileal endometriosis as a cause of ileus: a case report.

INTRODUCTION: Endometriosis is a benign condition affecting females of reproductive age. Although intestinal endometriosis is common, it is rarely manifested as an acute bowel obstruction secondary to ileal endometriosis. Enteric endometriosis should be considered as a differential diagnosis when assessing females of reproductive age with acute small bowel obstruction. CASE OUTLINE: A 41-year-old woman presented with symptoms and signs of an acute small bowel obstruction requiring emergency surgery. A small bowel resection was performed with end-to-end anastomosis. Histological examination demonstrated endometriosis with fibrosis and stricture of the ileal segment. This case is important to report as it highlights the diagnostic difficulty this particular condition pre sents to an emergency surgeon. CONCLUSION: In the differential diagnosis, endometriosis should be taken into consideration when assessing females of reproductive age who present with abdominal pain and small bowel obstruction.

[Acute lung injury and acute respiratory distress syndrome--what should we know?].

Acutelunginjury (ALI) and its more severe form acute respiratory distress syndrome (ARDS) are syndromes with a spectrum of increasing severity of lung injury defined by physiologic and radiographic criteria. There are many clinical disorders as sociated with the development of ALI/ARDS and can be divided into those associated with direct or indirect lung injury. Early detection and protective lung ventilation strategy contribute to lowering the mortality rate.

[Abdominal compartment sydrome in trauma patients].

Intra-abdominal compartment syndrome (ACS) are increasingly recognised to be a contributing cause of organ dysfunction and mortality in critically ill patients. The term abdominal compartment syndrome (ACS) describes the clinical manifestations of the pathologic elevation of the intra abdominal pressure (IAP). This syndrome is most commonly observed in the setting of severe abdominal trauma. ACS affects mainly the respiratory, cardiovascular, renal, gastrointestinal and central nervous system. Preventing ACS by the identification of patients at risk and early diagnosis is paramount to its successful management. Because of the frequency of this condition, routine measurement of intra abdominal pressure should be performed in high risk patients in the intensive care unit. Surgical decompression is definitive treatment of fully developed abdominal compartment syndrome, but nonsurgical measures can often effectively affect lesser degrees of IAH and ACS.

[Transfusion practice in trauma patient].

Anemia is common in critically ill patients and carries risk of reduced oxygen carriage and worse outcomes. Transfusion, however, carry their own risk, and the physician must balance the risks of anemia with the risk of transfusion in each patient. Some recent studies compared a liberal with a restrictive approach to transfusion, and a clinical practice guidelines were made. This protocols consider that acute hemorrhage has been controlled, the initial resuscitation has been completed, and the patient is stabile in the intensive care unit without ongoing bleeding. The trigger for PRBC transfusion in patients without severe cardiovascular disease is hemoglobin g/dL (or a hematocrit %).

[Laparoscopy in the evaluation of blunt abdominal trauma].

Laparoscopic diagnostics provides fast, reliable, clear, and obvious information on extent and depth of abdominal organs injury with minimizing additional trauma to the patient. It is performed without any specific preparations and, if needed, it may be promptly converted into conventional laparotomy. Through use of optical equipment with various refraction angles and through variable patient positioning, laparoscopic technique enables visualization of whole abdominal cavity. In approximately 20% of cases of unclear findings, and after other performed diagnostic procedures, laparoscopy provides definitive diagnosis. Abdominal surgeons are familiar with this method, making interpretaion of the results very fast and reliable and, what is the most important, this method avoids additional trauma caused by conventional laparotomy.

[Surgical treatment of injuries of the stomach and duodenum in abdominal trauma].

Injuries of the stomach and duodenum have an important place in abdominal trauma, even though that the isolated injuries are rare. This kind of injury is most commonly associated with injuries of other abdominal organs. This retrospective study has been done at the Department of Emergency Surgery, Clinical Centre of Serbia, during the period from January 2004. until January 2009. The study included 36 patients diagnosed intraoperatively with the injury of the stomach and duodenum. The most common mechanism of harming were injuries due to blunt trauma (41.7%), the ones followed by gunshot wounds (30.5%), and the least were stab injuries (27.8%). With the majority of patients has been conducted sutures (46.3%) and serosation (30.6%) of the stomach and duodenum. In 24 (66.7%) patients on admission have been done ultrasound of the abdomen, in 6 (16.7%) abdominal CT was done, in 4 (11.1%) peritoneal lavage have been done and the x-ray of the abdomen was performed in 3 (8.3%) patients. Specific complications had 1 (2.8%) patient, while 14 (29.9%) patients have had non-specific complications. Total mortality has been 33.3%

[Surgical treatment of pancreatic injuries in severe abdominal trauma].

In spite of its low incidence, pancreatic injuries hold important place in abdominal trauma because of diagnostic difficulties, severe potential complications, therapeutic challenges, and high mortality rates. These injuries are related with specific morbidity and are very often accompanied with injuries of other organs. This retrospective study included 31 patients treated at The Clinic for Emergency Surgery of Clinical Center of Serbia during the period of 2004-2009 with intraoperativelly confirmed diagnosis of pancreatic trauma. The most common mechanism of injury was blunt trauma (83.9%). Among available diagnostic methods, abdominal ultrasound was characterized with high incidence of false-negative findings (33.3%) while for CT it was at 16.6%. The type of surgical procedure was related to degree and severity of injury. Specific complications occurred in 22.6% of patients, while mortality rate was 25.8%. The creation of unambiguous algorithms for optimal treatment of patients with pancreatic trauma require multi-centric prospective studies.